Provider Demographics
NPI:1821703646
Name:BOURCY, CARLY
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:BOURCY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32452 HIGHWAY 47
Mailing Address - Street 2:
Mailing Address - City:MORA
Mailing Address - State:MN
Mailing Address - Zip Code:55051-6271
Mailing Address - Country:US
Mailing Address - Phone:763-482-4438
Mailing Address - Fax:
Practice Address - Street 1:1994 E RUM RIVER DR S
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MN
Practice Address - Zip Code:55008-2663
Practice Address - Country:US
Practice Address - Phone:763-689-5385
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-16
Last Update Date:2023-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
MN374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician